Nipple confusion (or nipple-teat confusion): difficulties of a baby to feed at the breast after drinking milk from a baby bottle teat.

Controversy

It has been debated for years whether nipple-teat confusion exists or if it is a misconception. The truth is that we can encounter everything: babies who can suckle at the breast, a bottle teat, a pacifier, and nipple shields interchangeably, and others who get a bottle teat in their mouths and don’t seem to know how to feed at the breast anymore or don’t even want to breastfeed anymore.

Challenges

There are two main challenges with bottle feeding, and both are related: the content (the milk) and the recipient (the bottle). Firstly, bottle teats; as much as advertising and marketing of manufacturers claim that their product resembles the mother’s nipple the most, in reality, none are similar to a mother’s nipple. Sucking on a plastic teat or sucking on a breast nipple requires different movements of the baby’s tongue and mouth muscles. Secondly, the volume of milk that babies usually receive from a formula bottle is much greater than what they get from feeding at their mother’s breast. If we add that the time it takes to get milk out of a bottle is much less than the time a baby needs at the breast, we can see that frustration is inevitable. And this is the key to the reason why a large number of babies give up breastfeeding.

What’s the behavior of a baby with nipple confusion?

Usually, a baby suffering from nipple-teat confusion is restless when feeding at the breast and even refuses the breast. Some babies may even refuse to be put in a breastfeeding position by crying and putting their hands in front of the breast.

They usually start by showing some difficulties when latching on; they have trouble knowing where the breast is and move their mouth from one side to the other over the nipple, and they seem to have trouble starting to suckle. When they manage to latch, they are nervous, make noises, and move around a lot at the breast; they don’t seem to relax and even pull on the nipple nervously. However, this behavior should not be confused with a breastfeeding crisis.

If the confusion progresses, this is when babies do not want to feed at the breast anymore; they even react aggressively when they are approached towards the breast, making the mother desperate and making everyone understand that they do not want to breastfeed anymore.

Suction from a teat

Contrary to what it may seem, for babies, feeding from a bottle is not easier than suckling at the breast.

The suction they do at the breast is much more physiological and allows them to control swallowing and breathing much better, making it a much less stressful experience.

When babies feed from a bottle, they have to put their tongues in front to stop the milk flow and avoid choking.

This is not easier or more difficult for them, but it’s completely different. The movements they make to extract the milk from the breast are very complex, and they “unlearn” how to do this.

In addition, receiving large amounts of commercial formula milk in a very short time makes the experience at the breast frustrating and annoying because it takes a lot of time and patience.

When supplementing a baby with additional milk is recommended because of suboptimal sucking, there should be caution with the use of the bottle, as the administration of the additional milk should be slow, respecting the physiology of the sucking cycles and the baby’s hunger.

How to attend to the confusion?

Each baby and each mother need to be assessed to understand the specific individual situation. If the confusion is beginning and the baby has had bottles for a short time, the most cautious thing to do would be to remove them. We are talking about eliminating the bottle as a method to offer milk, not about eliminating expressed breast milk or formula milk. If the baby needs supplementing or if mixed feeding has been chosen, it is not possible to withdraw it all at once. So milk should be given in something other than a bottle and with another method to reduce the confusion as much as possible.

Different methods of supplementation can be used to see which one works best for the family. The syringe-finger technique can be especially useful, as it helps the baby place their tongue in a position similar to the one they would need to when breastfeeding: a low, extended, and finally grooved tongue position. This way, the baby can practice and train to return to the breast.

Other things to consider

Another important thing is not forcing the baby to latch on. They have to relate to breastfeeding as an option, not as an obligation. Keeping the baby close to the breast in skin-to-skin contact is very helpful, but when the mother brings them closer, she should avoid “inviting” her baby to suckle as much as possible. It should be the baby who makes the step of looking for the breast and suckling.

Co-sleeping close together at night and with little clothing can be useful, as this sustained contact can help the baby locate where the milk comes from.

The baby seems to get encouraged to nurse but protests after a short while…

This is also quite common. Babies may begin to suckle relaxed, and as time passes, they may start to get uncomfortable. This is because the milk flow rate at the breast is not as fast as with a bottle. It is very positive that the baby wants to feed at the breast, so the mother can take advantage of this and help to make it easier for them.

Firstly, the mother can try to perfom breast compressions, which makes it easier for breast milk to come out a little faster and the baby does not get upset. The mother can actively press her breast when she sees that the baby is getting restless, so a stream of breast milk comes out and the baby becomes usually calmer.

Another thing to try is to use a supplemental nursing system so that the milk flow is more constant and the baby doesn’t lose interest in suckling. This blog post provides more information on how to use a supplemental nursing system and some tricks so the baby does not get used to feeding only from the tube.

How long will it take to solve nipple-teat confusion?

This is probably the most difficult question to answer. It may not be easy at all, and it can take weeks or months to reverse the process.

This is an intensive process that requires time and a lot of determination. No one can tell how long a baby will take to succeed, and no one knows if the mother will get tired of it.

What if they don’t succeed?

This can happen, and it’s not always possible to get a baby with nipple confusion to breastfeed again. If this is the mother’s wish, it is important that she feels that she has tried.

 

References

Huang, Y. Y., & Huang, C. M. (2006). Hu li za zhi The journal of nursing, 53(2), 73–79.

Zimmerman, E., & Thompson, K. (2015). Clarifying nipple confusion. Journal of perinatology : official journal of the California Perinatal Association, 35(11), 895–899. https://doi.org/10.1038/jp.2015.83